NCLEX3 2 Flashcards

Terms Definitions
Adult pH
thiothixene (Narane)
oxycodone (Percodan)
contains aspirin
What is Ptosis?
Burn victim
Maintain fluid balance
Cataracts: S/S
Loss of acuity
Normal WBC
4,500 - 11,000
pH greater that 7.54
Bladder infection: S/S
Urinary frequency
Discomfort in suprapubic area
live virus
12-15 months, 4-6 years
Glossopharyngeal responsible for differation of taste
QRS complex
*indicates ventricular depolarization to pump blood into aorta (ventricular systole)
*normally 0.04-0.11 second
*if longer indicates bundle branch block or other intraventricular conduction delay
Extrapyrimidal S/E
akathisia: motor restlessnes
dystonia: protrusion of tongue, abnormal posturing
pseudoparkinsonism: tremors, rigidity
dyskinesia: stiff neck, difficulty swallowing
Scoliosis: S/S
thoracic area is asymmetrical
noticeable distorted
Aspirin compounds can increase bleeding time
Should not be taken prior to surgical procedure
Circulatory/Inflammatory issue: S/S
Lower leg edematous
Hyperthyroidism: S/S
Anxiety with extreme nervousness
Related to increase in metabolic rate
Cardiac strip times:
PR: 0.12-0.2
QRS: 0.04-0.1
pH less than 7.35
Acidic (acidosis)
is an intermitten, reversible obstructive airway problem characterized by exacerbations and remissions. between attacks the client is generally asymptomatic. It is a common disorder of childhood but may also cause problems throughout adult life.
*heard on expiration
*are rumbling in quality
Draining abcess with no dressing: precaution
Abnormal Involuntary Movement Scale
Measures Tardive Dyskinesia
DVT: Goal
Decrease inflammatory response in affected extremity and prevent embous formation
Harmful of offensive touching of another person
Unless court ordered clients have a right to refuse medication, even if client is psychotic
Restraining a client to prevent injury to self or others is appropriate
Assualtive Client
Restore client's self-control and prevent further loss of control
Priority is to maintain milieu of safety by restoring client's self-control
Quick assessment of situation
Psychological intervention
Chemical intervention
Possible physical control
Erikson Stage:6-12 yrs
Industry vs inferiority
Developing social, physical & learning skills
Toys: Maintain contact w/ peers & school. board games, card games & hobbies (stamps, puzzles & video games).
What is the normal PaCO2 value?
is characterized by a slow deterioration of thyroid function, primary in older adults 5 more times more frequently in women 30-60 than in men. Myxedema coma is a life-threatening form of hypothyroidism.
Infant: stool
Black and and sticky
Suggestive of blood in stool
Neutropenic patient
Infection may cause morbitiy and fatality
Place client in private room
Limit and screen visitors and hospital staff with potentially communicable illness
Depression: Behavior
Client sits immobolized for long periods of time
Hypersensitivity Reaction
Fine macular rash
Stop medication and notify doctor
Requires immediate action
9 year old: death
adult concept of death
Regular insulin
Onset 0.5- 1 hour
Peak 2-4 hours
Duration 6-9 hours
Distended abdomen and splenomegaly
Possible internal bleeding
Life threatening situation
Cystic fibrosis: inherited
Inherited by autosomal recesive trait
Both mother and father carry recessive gene
Dopaminergic Therapy Adverse Effects
Impaired Concentration, Hypotension, GI upsets
What are normal WBC values?
5,000 - 10,000
What is the antidote for acetaminophen?
Mucomyst (N-acetylcysteine)
Fever is the point heat production passes heat loss
Ice pack on the head contemplate a temped bath
Take acetaminophen or ibuprofen to prevent a rapid rise that may cause seizure
If none of these work at 100.4 F can be tolerated can rise to dangerous levels especially in the afternoon.
F-Fahrenheit Greater 100.4-100.8(38C)
E-Endogenous Pyrogens Reset the hyperventilate system
V-Volume needs increase secondary to heat loss ex; increase metabolism shivering sweating evaporation and vazo dilation
E-Evaluate the source via labs; CBC with differential a urinalysis a blood culture and chest x-ray
R-Risk factors viral or bacterial illness environmental factors tissue damage and biological agents and endocrine system disorders Greater than 107F equals death or irreversible brain damage. These patients are at high risk of dehydration due to sweating. Give a lot of fluids fever peaks in late afternoon
is characterized by decrease in the PTH level, resulting in hypocalcemia and elevated serum phosphate levels, severe hypocalcemia results in tetany.
"I don't believe I have diabets. I feel perfectly fine"
Comes in 30 ml vials
Advise parents to have full dose for each child
Dose range from 10-30 ml
Fetal early declerations
A slowing early in contraction
Normal finding
Occurs in response to compression of fetal head
Uniform shape corresponds to intrauterine pressure as uterus contracts
Does not indicate fetal distress
Do not touch bed to avoid counter shock
Equipment should be checked every 8 hours
Equipment should be plugged in at all times
Infant assessment: last
All invasive procedures, eyes, ears, mouth, should be done last
Will not alter cardiopulmonary assessment of child if done at end
Ausculatate heart, lungs, and abdomen when child is quiet
Palpate and then percuss
Minor head injury: unexpected outcomes
Blurred vision
Drainage from eyes, ear, or nose
Slurred speech
Worsening headache
should be reported to doctor immediately
Tripiling of birth weight
Should occur at one year
Insulin level remains high while glucose level declines
Diaphoresis, confusion, tachycardia
Restlessnes, headache, weakness, irritability, apprehension, lack of muscle coordination,
Blood transfusion: Hemolytic reaction
Lower back discomfort, hypotension, chills
Lithium Toxicity Early S/E
fine tremors, nausea, vomiting, diarrhea
Pituitary dwarfism S/S
delicate features, appear younger than chronological age, fine smooth skin, delayed sexual maturity, small size with normal body proportions
Consent form
Can't sign if patient has been drinking alcholol or premedicated for surgery
Notify physician
Vesicular lung sounds
*heard over peripheral lung areas, including bases
*sounds are low-pitched with a soft, ablmost breezy quality
Chest tube: Flucuations
Flucuations stop with rexpansion of lung
X ray will confirm
Demtia early onset: S/S
Impaired concentration and memory loss
Cholinergic Blockers Nursing Interventions
Provide Fluids, Increase Dietary fiber, Monitor I&O, Monitor BP
Bronchopulmonary Dysplasia
neonatal lung injury usually a result of premature birth or respiratory support during perinatal period; poor formation of alveoli; hypoxema and hypercapnea; pulmonary hypertension, Classic findings: atelectasis, squamous metaplasia, alveolar epithelial cell hyperplasia, airway smooth muscle hypertrophy. New findings: from gentler ventilation with surfactant, less of everything but prominent airway reactivity (creating asthmatics)
What is the therapeutic range for Theophylline (aminophyline?
10-20 mcg/mL
Complete Compensation
occurs when the buffers have achieved homeostasis and pH is fully corrected.
Myoclonic Seizure
sporadic jerks, usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent, these seizures may result in dropping or involuntarily throwing objects.
Hip arthroplasty
Full weight bearing or flexion of more than 90 degrees should be avoided to prevent dislocation of prothesis
Intact rubber caps should be on walker to prevent accidents
Suspected drug overdose
Place client in a quiet darkened room
Sensory stimulation may further agitate client
Greeting the client in a warm and friendly manner may agitate client
Renal calculi pain
Location of pain depends on location of renal stone
Character of pain changes depending on location or movement of stone
Post-traumatic stress syndrome: out of apartment activities
Join a support group
Delusions of reference
false beliefs that people or public events are directly related to the individual
Treatment For Chronic Bronchitis
Similar to that of Emphysema; Bronchodilator therapy, beta-adrenergic agonists,corticosteroid therapy, oxygen and saturation therapy, chest physiotherapy,
What is the normal PTT value?
20 - 45 seconds
Mrs. Fischner's physician diagnosed that she has rheumatoid arthritis. With this condition, the client's chief complaint is persistent joint pain and stiffness. Pain and stiffness associated with rheumatoid arthritis is most often first noticed in the joi
(A) Hands
Rationale: Clients with rheumatoid arthritis usually experience discomfort in the proximal finger joints of the hands before any other joints of the body. Although rheumatoid arthritis can eventually spread to any or every joint, the symptoms of rheumatoid arthritis usually are noticed in the finger and hand joints prior to the joints of the arms, legs and neck.
Nx for pt with tracheostomy
Ineffective airway clearance due to secretions
Prevent spread of infection
Place clients in different rooms with different nurses
Infant with cleft lip and palate: upper airway congestion
Suctioning is contraindicated
Place infant on left side to facilitate drainage of mucuous from upper airway and promote adjustment to breathing through the nose
Stage IV pressure ulcer
*continuation of Stage III with damage to muscle, bone, tendons or joint capsule
*may be accompanied by sinus tracts and underming of surrounding tissue
Tube Feeding via Levin Tube
Clamping of tubing between feedings prevents introduction of air and liquid loss
Clean, not sterile, supplies are required
Physician will order amount of feedings, usually begin with a small amount and increase 50-100 ml until nutritional requirements are met
Tube feeding given at room temperature to minimize intestional cramping
Inapproprite IV infusion for child
D5W @ 2000ml/24 hr (84 ml/hr):excessive amount and no electrolytes
Call doctor to clarify order
Fractured right hip S/S
Leg appears to be shortened, is adducted, and externally rotated
Peds Normal Pulse & RR
Newborn pulse: 100-160 RR 30-60
1-11 mo pulse 100-150 RR 25-35
1-3 yr pulse 80-130 RR 20-30
3-5 yr pulse 80-120 RR 20-25
6-10 yr pulse 70-110 RR 18-22
10-16 yr pulse 60-90 RR 16-20
When considering questions that deal with nurses communicating with clients, the item writers typically look for the testtaker
to choose the answer that demonstrates the nurse empathizing with the client.
Hence, steer clear of answers that contain the fo
Frequently, answers contain multiple parts. It is important to remember that all components of an answer must be correct.
There is no such answer that is partially right. It is entirely correct or it is not the answer.
Tools physical assessment
1 Inspection use of eyes to gather data careful observations can provide clues such as respiratory system muscle skeletal and nero system skin integrity and emotional/mental status
2 Osculation listen to sounds by the organs and tissues of the body frequently used to asses the heart lung neck and abdomen. These sounds are characterized according pitch intensity and duration
3 Percussion is used for assessing the size position and density of underlying structures. Use sharp tapping produces vibrations and subsequent sound waves that interpretive as air fluid or solid material
4 Palpation use of hands fingers to gather data through touch. The characteristics of body texture temperature size shape and movement may be distinguished by different parts of the hands and fingers.
5 The palm and ulnar surfaces are used to distinguish vibrations in the dorsal side is the best for temperature. Bi manual technique uses both hands to entrap an organ or mass between the fingertips to better asses the size and shape.
Infant: 3 months behavior
Holds head errect when sitting on the examination table
Turns head to try to locate sound
Smiles spontaneously when he sees his mother
What are the meds most often used to treat status epilepticus?
diazepam (Valium)
phenytoin (Dilantin)
phenobarbitol (Luminol)
When referring to medical diagnoses that are progressive in nature and asking about early signs and symptoms of the disease
progression, choose "fatigue" as the answer. Fatigue is often the earliest sign that illness is threatening or has begun.
Conversely, when referring to medical diagnoses that are progressive in nature and asking about late signs and symptoms of the disease progression, choose the answer that reflects advanced physiological changes and/or deformities. These changes typically occur over a period of time and are therefore not seen until the disease is advanced.
Unequal pupil size
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
A nurse reinforces information about the disease and recuperation to the client diagnosed with tuberculosis. The nurse determines that the client understands the information presented if the client states that it is possible to return to work when:
1. Fiv
2. Three sputum cultures are negative
Rationale: The client must have sputum cultures performed every 2 to 4 weeks after antituberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative because the client is considered noninfectious at that point. One negative sputum culture is not sufficient, and five negative cultures are unnecessary.
3 year old: Physical development
Walk up and down steps
Has a steady gait
Can stand on one foot momentarily
Jumps with both feet
What is Ortilani's Sign
The click that is heard or felt when the infant is supine and knees are flexed and hips are abducted = hip dyslpasia
When a question is describing the signs and symptoms a client is exhibiting, routinely the first symptom mentioned in the question is considered to be the priority. There is often
intent or purpose in the order in which things are listed. The answer chose
More often than not, remembering Airway, Breathing, and Circulation will guide you to the correct answer. In addition to the ABCs being a viable solution to a question, it has also been noted that frequently when infection is offered as an option, it is the correct answer (approximately 75% of the time). The
seriousness of the infection should also be considered by the test-taker.
Of the following symptoms, which would indicate that a client has a deficiency of riboflavin?
(A) Ecchymosis
(B) Dry, cracked lips and mouth
(C) Night blindness
(D) Anorexia, weight loss, and fatigue
(B) Dry, cracked lips and mouth
Rationale: Insufficient amounts of Riboflavin (or Vitamin B2) leads to development of dry skin lesions, usually found in or around the mouth. Riboflavin is not stored in the body, and therefore must be restored through dietary supply. Foods that contain riboflavin include dairy products, eggs, whole-grain enriched breads and cereals, liver, and green leafy vegetables. Ecchymosis (bruising) is a result of a decrease in essential clotting factors in the blood, as in Vitamin K deficiency. Night blindness is a result of Vitamin A deficiency. Anorexia, weight loss and fatigue are symptoms of Thiamin (or Vitamin B1) deficiency.
Wrap her hands in soft "mitten" restraints
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?
A client is being discharged from the hospital after treatment for new onset atrial fibrillation. The client was started on warfarin (Coumadin). The LPN/LVN reviews the client's discharge instructions. Select all of the following foods that should be limi
(A) Kale
(B) Spinach
(C) Green beans
(D) Broccoli
(E) Brussels sprouts
Rationale: Warfarin is an anticoagulant used to prevent thromboembolic events for at risk clients. Vitamin K reverses the effects of warfarin (Coumadin). Good dietary sources of vitamin K include green leafy vegetables, broccoli and green beans. Celery contains very low sources of vitamin K.
While looking over a client's laboratory findings, the day shift LPN/LVN notices that the serum potassium of the client is 4.1 mEq/L. Which of the following is the most appropriate nursing action after discovering this information?
(A) Document this norma
(A) Document this normal finding in the medical record
Rationale: The normal range for serum potassium is 3.8 to 5.0 mEq/L. The client's potassium level is within normal range. The correct nursing action would be to document this finding, answer (A). There is no need for the physician to be notified immediately, and further interventions are not necessary for a normal finding.
Post-traumatic stress syndrome: desensitization
Go for a walk, take a bus ride, day trip with friend
Questions often refer to the health and well-being of clients.
For these questions, look for answers that teach or encourage the client to avoid using alcohol, caffeine, and tobacco.
Nurses seldom encourage clients to limit usage of these products.
There are usually questions on the nutritional value of foods on the NCLEX-RN and -PN.
When you come across a question that is about the nutritional value of food, always choose the answer that contains chicken.
It is high in protein for healing, and it is low in fat for health. This makes it a prime choice for a healthy food.
Some questions ask for what I call "negative" responses. These questions use phrases such as "The nurse would not do . . ."; "The nurse would not assess . . ."; ". . . all but which . . ."; "The nurse/client would/should avoid . . ."; and "The nurse/clien
Unless contraindicated by the surgical procedure itself, select the answer that offers the position of choice for postoperative clients as low Fowler's. This position facilitates lung expansion and decreases pressure on the vena cava.
Mrs. Strobell is walking in the hallway with the nursing assistant. She experiences sudden onset of angina. Which of the following should be the first action taken by the LPN/LVN?
(A) Call the physician immediately
(B) Instruct Mrs. Strobell to relax and
(B) Instruct Mrs. Strobell to relax and discontinue all muscle movement
Rationale: Angina is pain in the chest that is caused by an insufficient flow of oxygen to the cardiac muscle. Muscle activity that occurs with movement increases the oxygen demand of the cardiac muscle. Discontinuing all movement will decrease the oxygen demand of the muscle. It is important to administer supplemental as soon as possible, and the client should not walk or stand any more than necessary while experiencing angina. While a wheelchair and an oxygen tank are being retrieved, the nurse can instruct the client to remain still and relax as much as possible. Of the answer choices, answer (B) is the correct initial action. Once back in her room, Mrs. Strobell can be assisted to bed to lie down.
A licensed practical nurse witnesses an accident in which a victim was hit by a car. The nurse stops at the scene of the accident and administers safe care to the victim, who sustained a compound fracture of the femur. The victim is hospitalized and later
3. The Good Samaritan Law will protect the nurse if the care given at the scene is not negligent
Rationale: A Good Samaritan law is passed by the state legislature to encourage nurses and other health care providers to provide care to a person when an accident, emergency or injury occurs, without fear of being sued for the care provided. Called immunity from suit, this protection usually applies only if all of the conditions of the law are met, such as the health care provider receives no compensation for the care provided, and the care given is not willfully and wantonly negligent.
A client has an order for valproic acid (Depakene) 250 mg once daily. To maximize the client's safety, the nurse plans to schedule the medication:
1. With lunch.
2. At bedtime.
3. After breakfast.
4. Before breakfast.
2. At bedtime
Rationale: Valproic acid is an anticonvulsant that causes central nervous system (CNS) depression. Its side effects include sedation, dizziness, ataxia and confusion. When the client is taking this medication as a single dose, administering it at bedtime negates the risk of injury from sedation and enhances client safety.
Every so often you find questions that seem easy or obvious. These questions may make you doubt your understanding of the question. I call these questions "ah-ha" moments. When you are deep into the test and concentrating with all your ability and one of
Avoid answers that question a client about his or her feelings, negate one's feelings, or tell the client how to feel. Feelings are personal and should be respected.
A psychotic client is belligerent and agitated, making aggressive gestures and pacing in the hallway. To ensure a safe environment, which of the following is the nurse's highest priority?
1. Assist other staff in restraining the client
2. Provide safety f
2. Provide safety for the client and other clients on the unit
Rationale: A psychotic client who is out of control may require seclusion to ensure the safety of the client and other clients in the unit. The correct option is the only one that addresses the safety needs of both the client and others. Options 1 and 3 do not provide for the client's safety needs or rights, respectively. In addition, specific policies and guidelines must be followed with regard to restraining a client. Option 4 may be ineffective and does not address the safety needs of others in the unit.
A nurse is orienting a nursing assistant to the clinical nursing unit. The nurse should intervene if the nursing assistant did which of the following during a routine hand washing procedure?
1. Kept the hands lower than the elbows
2. Washed continuously f
4. Dried the hands from the forearm down to the fingers
Rationale: Proper hand washing procedure involves wetting the hands and wrists and keeping the hands lower than the forearms so water flows toward the fingertips. The nurse uses 3 to 5 mL of soap and scrubs for 10 to 15 seconds using a rubbing and circular motion. The hands are rinsed and then dried, moving from the fingers to the forearms. The paper towel is then discarded, and a second one is used to turn off the faucet to avoid hand contamination.
An adult client is brought to the emergency room by an ambulance after being hit by a car. The client is unconscious and in shock. A perforated spleen is suspected, and emergency surgery is required immediately to save the client's life. No family members
2. Transport the client to the operating room immediately
Rationale: Generally there are only two instances in which the informed consent of an adult is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. It is inappropriate to ask the hospital chaplain to sign the consent form. Requesting that the nursing supervisor initiate a court order for the surgical procedure delays the necessary life-saving intervention. Although the family needs to be notified, calling a family member to obtain telephone consent before the surgical procedure also delays necessary life-saving intervention.
When assessing a client after a stroke, the nurse notes that there is an impairment of the ability to read, write, speak, listen, and comprehend. The nurse identifies this as:
1. Ataxia
2. Aphasia
3. Dysphagia
4. Agnosia
2. Aphasia is the inability to express oneself through speech and language.
Mrs. Wilkins is in her second post-op day with a right-above-the-knee amputation. She asks the nurse why her stump must be rewrapped every day with an elastic bandage. Which of the following is the most appropriate reason for this procedure?
(A) "The band
(B) "The bandage helps shape the stump and shrinks the stump size."
Rationale: The site of a new amputation will develop a large amount of edema. Stump wrapping with an elastic bandage shrinks and shapes the stump for prosthesis construction. Therefore, answer (B) is correct. The prosthesis will not be sized and constructed until the stump is cone shaped and the size is no longer changing. Gauze bandages are used to absorb blood and drainage. Dehiscence is the separation of the edges or reopening of a closed incision. With appropriate suturing, normal movement should not cause dehiscence. Antiembolism stockings are used to aid circulation in uncompromised limbs.
A client who has been admitted to the mental health unit with obsessive compulsive disorder repeatedly cleans the bathroom fixtures. The client has become enraged and has started to bite and kick the roommate for occupying the bathroom. Which of the follo
3. Provide a safe environment for both clients
Rationale: The first action of the nurse is to provide an environment that is safe for both clients. This may take a variety of forms, depending on the individual circumstance, agency protocols, and written physician orders. Seclusion, chemical restraint, and physical restraint are used only when alternative and less restrictive measures are not effective in controlling the client's behavior.
A nurse assists in developing a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which of the following will the nurse suggest to include in the client's plan of care?
1. Limit visiting time to 60
4. Place a sign on the door of the client's room indicating the need to speak to the nurse before entering
Rationale: the client's room should be marked with appropriate signs stating the need to speak to the nurse before entering because of the risk of exposure to radiation when in the client's room. The client should be placed in a private room at the end of the hall because this location provides less chance of radiation exposure to others. A lead container and long handled forceps should be kept in the client's room at all times during internal radiation therapy. If the implant becomes dislodged, the nurse should be pick up the implant with long handled forceps and place it in the lead container. The nurse does not reinsert it. Visiting time is limited to 30 minutes per visit.
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